Revision 17-1; Effective November 1, 2017

 

 

7100 Billing and Claims Payment

Revision 17-1; Effective November 1, 2017

 

The following services may be billed under the Community Living Assistance and Support Services (CLASS) Program:

  • Case Management
  • Community First Choice (CFC) PAS/HAB
  • Transportation-habilitation Services
  • Supported Employment
  • Employment Assistance
  • Prevocational Services
  • Nursing Services (e.g., registered nursing, licensed vocational nursing, specialized registered nursing, specialized licensed vocational nursing)
  • Physical Therapy
  • Occupational Therapy
  • Speech and Language Pathology
  • Specialized Therapies, that include:
    • Massage Therapy
    • Recreational Therapy
    • Music Therapy
    • Aquatic Therapy
    • Hippotherapy
    • Therapeutic Horseback Riding
    • Auditory Enhancement Training
  • Dietary Services
  • Behavioral Support
  • Cognitive Rehabilitation Therapy
  • Support Family Services
  • Continued Family Services
  • Transition Assistance Services
  • Respite
  • Adaptive Aids (vehicle modifications are billed as adaptive aids)
  • Dental Services
  • Minor Home Modifications
  • Services specifically for individuals who choose the Consumer Directed Services (CDS) option that include:
    • Financial Management Services
    • Support Consultation

Note: For purposes of this section, the term "provider agency" means a CLASS Case Management Agency (CMA) or Direct Service Agency (DSA), as applicable.

Each DSA must ensure that each CLASS program service is provided to an individual in accordance with Appendix C of the CLASS Waiver Application. The approved service definition for each of the services described in this section are contained within the Texas Administrative Code (TAC). Those service definitions are located in 40 TAC §45.103, Definitions.

Each CLASS service delivered to an individual must be recorded as a distinct event by each service provider. Documentation of services delivered may be provided on Form 3625, CLASS/CFC – Documentation of Services Delivered, by fax or via the electronic visit verification (EVV) system.

Service delivery documentation must be completed according to the Texas Health and Human Services Commission (HHSC) instructions.

Each provider agency must designate a timekeeper to sign Form 3625 to verify its accuracy.

CLASS payment rates are set by the HHSC Rate Analysis. For current rates, see https://rad.hhs.texas.gov/.

 

7110 Case Management Agency (CMA) Services

Revision 17-1; Effective November 1, 2017

 

Case management services provided after the individual has been enrolled in the CLASS program are based on a monthly rate. The number of case management units needed by the individual are determined by the service planning team (SPT) and approved by HHSC on the Individual's Plan of Care (IPC). The monthly case management fee may only be billed during a month when a billable contact has occurred. The case manager must record time spent providing case management services on Form 3625, CLASS/CFC – Documentation of Services Delivered.

If the individual/LAR requests a fair hearing before the effective date of the termination, as specified in the written notice of CLASS Program services and CFC services, the CMA must continue to provide services to the individual.

 

7120 Direct Services Agency (DSA) Services

Revision 17-1; Effective November 1, 2017

 

If the individual/LAR requests a fair hearing before the effective date of the termination of CLASS Program services and CFC services, as specified in the written notice, the DSA must continue to provide services to the individual in the amounts authorized in the IPC while the appeal is pending.

 

7121 Personal Service Agreement or Contract with Another Agency

Revision 17-1; Effective November 1, 2017

 

With the exception of CFC PAS/HAB, transportation-habilitation and in-home respite, the DSA may contract with an individual or agency to provide CLASS services. The DSA is responsible for ensuring all service providers meet required direct service provider qualifications and training requirements.

CLASS services provided through a personal service agreement or contract with the DSA must be recorded on Form 3625, CLASS/CFC – Documentation of Services Delivered, or by fax and authenticated by the service provider.

 

7122 Minor Home Modifications and Adaptive Aids

Revision 17-1; Effective November 1, 2017

 

The DSA will only be reimbursed for adaptive aids and minor home modifications included in Appendix I, Adaptive Aids, and Appendix II, Minor Home Modification Services, and authorized by HHSC on the individual's IPC. Minor home modifications and adaptive aids purchased by the DSA must be recorded on Form 3625, CLASS/CFC – Documentation of Services Delivered, and signed by the appropriate representative of the DSA. The DSA representative must be a:

  • program director or meet program director qualifications;
  • registered nurse (RN); or
  • licensed vocational nurse (LVN).

The DSA must have a signed and dated invoice from the vendor indicating work performed and/or services delivered and the date of completion. The DSA must keep required documentation related to procurement and cost.

 

7200 Billable Activities

Revision 11-1; Effective June 13, 2011

 

 

 

7210 Case Management

Revision 17-1; Effective November 1, 2017

 

The following activities are billable and must include a face-to-face or telephone contact with the individual/LAR:

  • assessing the individual's needs;
  • enrolling the individual into the CLASS Program;
  • developing the individual's service plan;
  • coordinating the provision of CLASS services;
  • monitoring the effectiveness of the CLASS services and the individual's progress toward achieving the outcomes identified;
  • revising the individual's service plan, (limited to time spent meeting with the SPT);
  • accessing non-waiver services, including Medicaid State Plan services;
  • resolving crisis situations in the individual's life;
  • advocating for the individual; and
  • pre-enrollment assessment before the individual is enrolled in the CLASS program.

Note: A face-to-face or telephone contact with the paid caregiver (e.g., CFC PAS/HAB, transportation-habilitation staff, respite care provider, nurse, etc.) does not establish a billable activity.

Effective March 20, 2016, each case manager must have at least one face-to-face or telephone contact with the individual or LAR or other persons acting on behalf of the individual, such as an advocate or family member, per month to provide case management. Case management in the CLASS program is paid a monthly rate based on at least one billable contact. The CMA must ensure the service date billed for this contact agrees with the date of the actual billable contact.

Case management billing must be documented on Form 3625, CLASS/CFC – Documentation of Services Delivered, and supported by documented contact notes that include:

  • the date of contact;
  • the description of the case management provided;
  • the progress or lack of progress in achieving goals or outcomes in observable/measurable terms that directly relate to the specific goal or objective addressed;
  • the person with whom the contact occurred; and
  • the case manager who provided the contact.

 

7220 Nursing

Revision 11-1; Effective June 13, 2011

 

The following activities may be billed under the CLASS program if included in the individual's approved IPC:

  • direct delivery of nursing services by an RN or LVN within the scope of their licensure;
  • delegation activities performed by the RN, including the direct training and supervision of unlicensed persons in the performance of health-related tasks;
  • nursing assessments performed by the RN; and
  • participation on the SPT when the individual has an identified need for nursing services.

 

7221 Specialized Nursing

Revision 11-1; Effective June 13, 2011

 

Nursing services provided to an individual who requires tracheostomy care or is ventilator dependent must be billed to the CLASS program if included in the individual's authorized IPC.

 

 

7230 Therapies

Revision 11-1; Effective June 13, 2011

 

 

 

7231 Behavioral Support Services

Revision 17-1; Effective November 1, 2017

 

Behavioral support services are specialized interventions that assist an individual in increasing adaptive behaviors and replacing or modifying challenging or socially unacceptable behaviors that prevent or interfere with the individual's inclusion in the community.

A program provider must ensure the behavioral support services provider is a:

  • licensed psychologist;
  • provisionally licensed psychologist;
  • licensed psychological associate;
  • licensed clinical social worker;
  • licensed professional counselor; or
  • behavior analyst certified by the Behavior Analyst Certification Board, Inc.

The behavioral support services provider must have received training in behavioral support or have experience in providing behavioral support. The DSA may document a behavioral support provider’s compliance with this requirement by listing any training related to behavioral support the provider states has been completed. The DSA program director or RN may also document observation of positive outcomes for any individual receiving behavioral support services. The DSA may also document observation of the behavioral support provider by successfully completing the billable tasks listed below.

The following activities may be billed under the CLASS program if included in the individual's authorized IPC:

  • conducting a functional behavior assessment;
  • developing an individualized behavior support plan;
  • training and consulting with an individual, family member, or other persons involved in the individual's care regarding the implementation of the behavior support plan;
  • monitoring and evaluating the effectiveness of the behavior support plan;
  • modifying, as necessary, the behavior support plan based on monitoring and evaluating the plan's effectiveness; and
  • counseling and educating an individual, family members, or other persons involved in the individual's care about the techniques to use in assisting the individual to control challenging or socially unacceptable behaviors.

The behavioral support provider must provide justification for time required to develop an individualized behavior support plan. The justification should include time necessary to conduct the functional assessment, any review of individual records, and time spent developing an individualized behavior support plan.

Seclusion

CLASS rules prohibit use of seclusion during the provision of CLASS services. Seclusion is defined as the involuntary separation of an individual away from other individuals and the placement of the individual alone in an area from which the individual is prevented from leaving. Seclusion offers no beneficial purpose and presents a significant health and safety risk to the individual.

 

7232 Occupational Therapy, Physical Therapy, and Speech and Language Pathology

Revision 17-1; Effective November 1, 2017

 

A current physician's order for each therapy is required before the delivery of occupational therapy, physical therapy and speech and language pathology. Physician's orders are not necessary for an evaluation only.

The following activities may be billed under the CLASS program if included in the individual's authorized Individual Plan of Care:

  • direct contact with the individual;
  • time spent by a therapist to train the individual/legally authorized representative, primary caregiver or service provider in the proper use of an adaptive aid;
  • time spent teaching a service provider to reinforce therapy goals during activities of daily living (ADL);
  • time spent by a therapist to perform face-to-face evaluations to determine an individual's need for skilled therapy service, adaptive aids or minor home modifications; and
  • participation on the SPT may be billed as a professional service, only:
    • when the individual has an identified need for the service, and
    • for actual time spent in the capacity of the respective discipline.

The therapist must provide justification for time required to develop an assessment of the individual’s need for an adaptive aid or minor home modification. The justification should include time necessary to conduct the assessment and research regarding the most appropriate and cost-effective manner to meet the individual’s needs.

 

7233 Specialized Therapies

Revision 17-1; Effective November 1, 2017

 

Specialized therapy services must be related to the individual's disability. Specific therapeutic goals must be in place for each specialized therapy provided under the CLASS program to address the individual's disability. A current physician's order for each therapy is required before the delivery of specialized therapy services. Physician's orders are not necessary for an evaluation only.

The following activities may be billed under the CLASS program if included in the individual's authorized IPC:

  • direct contact with the individual;
  • time spent by a therapist to train the individual/LAR, primary caregiver or service provider in the proper use of an adaptive aid;
  • time spent teaching a service provider to reinforce therapy goals during ADL;
  • time spent by a therapist to perform face-to-face evaluations to determine an individual's need for skilled therapy service, adaptive aids or minor home modifications; and
  • participation on the SPT may be billed as a professional service, only:
    • when the individual has an identified need for the service, and
    • for actual time spent in the capacity of the respective discipline.

The therapist must provide justification for time required to develop an assessment of the individual’s need for and adaptive aid or minor home modification. The justification should include time necessary to conduct the assessment and research regarding the most appropriate and cost-effective manner to meet the individual’s needs.

The following services are available under specialized therapies and may be billed under the CLASS program if included in the individual's authorized IPC.

  • Massage Therapy must be provided by a licensed massage therapist.
  • Recreational Therapy must be provided by a certified therapeutic recreation specialist awarded by the National Council of Therapeutic Recreation Certification (NCTRC) or a therapeutic recreation specialist certified by the Consortium for Therapeutic Recreation/Activities Certification, Inc (CTRAC).
  • Music Therapy must be provided by a board certified music therapist awarded by the Certification Board for Music Therapists.
  • Aquatic Therapy must be provided by:
    • a licensed massage therapist;
    • a certified therapeutic recreation specialist awarded by the NCTRC;
    • a certified therapeutic recreation specialist awarded by the CTRAC; and
      • hold a certificate of completion of the "Basic Water Rescue" course from the American Red Cross; or
      • be certified by the American Red Cross as a lifeguard.
  • Hippotherapy must be provided by:
    • a riding instructor certified by the Professional Association of Therapeutic Horsemanship International as a therapeutic riding instructor or by the North American Riding for the Handicapped Association; and
    • a licensed occupational therapist;
    • a licensed occupational therapy assistant;
    • a licensed physical therapist; or
    • a licensed physical therapist assistant.
  • Therapeutic Horseback Riding must be provided by a riding instructor certified by the Professional Association of Therapeutic Horsemanship International or the North American Riding for the Handicapped Association as a therapeutic riding instructor.

Reimbursement Rates

The current specialized therapies unit rate ceiling per hour is located on the HHSC Rates Analysis website. For services with a unit rate ceiling, the rate negotiated with the provider agency must be at or below the approved ceiling rate; the negotiated rate then becomes the unit rate for that particular service.

Requisition Fees

Requisition fees are 10% of the expenditure for the specialized therapy.

 

7234 Cognitive Rehabilitation Therapy

Revision 15-2; Effective November 20, 2015

 

Cognitive Rehabilitation Therapy (CRT) assists an individual in learning or relearning cognitive skills that have been lost or altered, as a result of damage to brain cells or brain chemistry, in order to enable the individual to compensate for lost cognitive functions. CRT includes reinforcing, strengthening or reestablishing previously learned patterns of behavior, or establishing new patterns of cognitive activity or compensatory mechanisms for impaired neurological systems.

If an individual might need CRT, the assigned case manager must assist the individual in obtaining, in accordance with the Medicaid State Plan, a neurobehavioral or neuropsychological assessment and plan of care from a qualified professional as a non-CLASS program service.

A program provider must ensure a CRT service provider provides and monitors the provision of CRT to the individual in accordance with the plan of care and is a:

  • licensed psychologist;
  • licensed speech-language pathologist; or
  • licensed occupational therapist.

The plan of care for CRT is developed based on a neurobehavioral or neuropsychological assessment and plan of care from a qualified professional.

An acquired brain injury (ABI) is an injury to the brain that occurs after birth, is non-congenital and non-degenerative, and that disrupts the normal function of the brain. The definition of ABI also includes traumatic brain injury (TBI) and other brain injuries resulting from any anoxic condition. Additional information on acquired brain injuries is located on the website for the Texas Health and Human Services Commission office on Acquired Brain Injuries at https://hhs.texas.gov/services/disability/office-acquired-brain-injury.

 

7235 Dietary Services (Nutritional Services)

Revision 15-2; Effective November 20, 2015

 

The provision of nutrition services is defined in Texas Occupations Code, Chapter 701. A program provider must ensure dietary services are provided by a licensed dietician.

The following activities may be billed under the CLASS program. if included in the individual's authorized Individual Plan of Care:

  • assessing the nutritional needs of an individual and determining constraints and resources in the practice;
  • establishing priorities and goals that meet nutritional needs and are consistent with constraints and available resources;
  • providing nutrition counseling in health and disease;
  • developing, implementing and managing nutritional care systems; or
  • evaluating, changing and maintaining appropriate quality standards in food and nutritional care services.

 

7236 Auditory Integration/Auditory Enhancement Training

Revision 15-2; Effective November 20, 2015

 

Auditory integration/auditory enhancement is specialized training that assists an individual to cope with hearing dysfunction or over-sensitivity to certain frequency ranges of sound by facilitating auditory processing skills and exercising the middle ear and auditory nervous system.

A program provider must ensure the service is provided by a licensed audiologist or a licensed assistant in audiology. An individual must have an audiogram performed by a licensed audiologist as a pre-requisite for auditory integration/auditory enhancement training.

 

7240 Supported Employment, Prevocational Services and Employment Assistance

Revision 17-1; Effective November 1, 2017

 

Additional information regarding provision of supported employment, prevocational services, and employment assistance can be located in a guide available at hhs.texas.gov/services/disability/employment/employment-first/employment-guide-people-disabilities.

 

7241 Supported Employment

Revision 17-1; Effective November 1, 2017

 

Supported employment is a service that provides assistance to sustain competitive employment to an individual who requires intensive, ongoing support to be self-employed, work from home, or perform in a work setting at which individuals without disabilities are employed.

Competitive employment is employment that pays an individual at or above the greater of the applicable minimum wage or the prevailing wage paid to individuals without disabilities for performing the same or similar work.

A program provider must ensure a supported employment service provider:

  • is not the employer of the individual receiving the service or an employee of the individual's employer;
  • has a bachelor's degree or an associate’s degree in rehabilitation, business, marketing or a related human services field with six months of paid or unpaid experience providing services to people with disabilities;
  • has a high school diploma or a certificate recognized by a state as the equivalent of a high school diploma, with two years of paid or unpaid experience providing services to people with disabilities;
  • does not perform supervisory activities rendered as a normal part of the business setting;
  • does not provide supports to an individual who does not require such supports to continue employment;
  • includes transportation necessary for the individual's participation in supported employment;
  • provides ongoing supervision and monitoring of the individual's satisfaction and performance on the job; and
  • does not provide supported employment to an individual with the individual present at the same time one of the following CLASS program services is provided:
    • CFC PAS/HAB;
    • transportation-habilitation;
    • respite;
    • prevocational;
    • nursing; and
    • employment assistance.

A service provider of supported employment may not be the:

  • parent of the individual if the individual is under 18 years of age; or
  • spouse of the individual.

Before including supported employment on an individual's IPC, a program provider must ensure similar services are not available to the individual through a program funded under Section 110 of the Rehabilitation Act of 1973 or the Individuals with Disabilities Education Act (20 USC 1401 et seq.). If an individual is already employed and in need of assistance maintaining a job, a CMA should not refer the individual to HHSC. Instead, the provider should seek approval through the individual’s service plan to provide supported employment or other services needed to maintain an individual’s employment.

HHSC does not authorize payment for training that is not directly related to an individual's supported employment program. The following activities may be billed to the CLASS program if included in the individual's authorized IPC:

  • face-to-face or telephone contact with an individual at the individual's work site to provide training, support and intervention necessary to sustain the individual's employment;
  • face-to-face or telephone contact with an individual's legally authorized representative to sustain the individual's employment;
  • face-to-face or telephone contact with an individual's employment supervisor as necessary to sustain the individual's employment;
  • participation in SPT meetings; and
  • transporting an individual to and from the work site.

 

7242 Prevocational Services

Revision 17-1; Effective November 1, 2017

 

Prevocational services are services that are not job-task oriented and are provided to an individual to prepare the individual for employment and who the SPT does not expect to be employed, without receiving supported employment, within one year after prevocational services begin.

Before including prevocational services on an individual's Individual Plan of Care (IPC), a program provider must ensure similar services are not available to the individual through a program funded under Section 110 of the Rehabilitation Act of 1973, or the Individuals with Disabilities Education Act (20 USC 1401 et seq). HHSC does not provide any services similar to CLASS prevocational services; therefore, a Case Management Agency (CMA) is not required to obtain a denial from HHSC before including prevocational services on an individual’s IPC.

A program provider must ensure a provider of prevocational services:

  • has a bachelor's degree in a health and human services field, and two years work experience in the delivery of services and supports to persons with related conditions or similar disabilities; or
  • has one of the following:
    • a high school diploma and four years work experience in the delivery of services and supports to persons with related conditions or similar disabilities; or
    • a high school equivalency certificate issued in accordance with the law of the issuing state and four years work experience in the delivery of services and supports to persons with related conditions or similar disabilities.
  • does not provide prevocational services to the individual at the same time one of the following CLASS program services is provided:
  • CFC PAS/HAB;
  • transportation-habilitation;
  • respite;
  • prevocational;
  • nursing; and
  • employment assistance.

A service provider of prevocational services may not be the:

  • parent of the individual if the individual is under 18 years of age; or
  • spouse of the individual.

The following activities may be billed as prevocational services under the CLASS program if included in the individual's authorized IPC:

  • assessment of vocational skills an individual needs to develop or improve upon;
  • individual and group instruction regarding barriers to employment;
  • training in skills:
    • that are not job-task oriented;
    • that are related to goals identified in the individual's habilitation plan;
    • that are essential to obtaining and retaining employment, such as the effective use of community resources, transportation and mobility training; and
    • for which an individual is not compensated more than 50 percent of the federal minimum wage or industry standard, whichever is greater;
  • training in the use of adaptive equipment necessary to obtain and retain employment; and
  • transportation between the individual's place of residence and prevocational services site when other forms of transportation are unavailable or inaccessible.

 

7243 Employment Assistance

Revision 17-1; Effective November 1, 2017

 

Employment assistance is provided to an individual to help the individual locate competitive employment in the community.

A program provider must ensure an employment assistance service provider:

  • has a bachelor's degree or an associate’s degree in rehabilitation, business, marketing or a related human services field with six months of paid or unpaid experience providing services to people with disabilities;
  • has a high school diploma or a certificate recognized by a state as the equivalent of a high school diploma, with two years of paid or unpaid experience providing services to people with disabilities;
  • does not provide employment assistance to an individual with the individual present at the same time one of the following CLASS program services is provided:
    • CFC PAS/HAB;
    • transportation-habilitation;
    • respite;
    • prevocational;
    • nursing; and
    • employment assistance.

A service provider of employment assistance may not be the:

  • parent of the individual if the individual is under 18 years of age; or
  • spouse of the individual.

Before including employment assistance on an individual's Individual Plan of Care (IPC), a program provider must ensure similar services are not available to the individual through a program funded under Section 110 of the Rehabilitation Act of 1973 or the Individuals with Disabilities Education Act (20 USC 1401 et seq.).

An individual seeking employment assistance must apply for those services through HHSC before receiving employment assistance services through CLASS services. CLASS may provide employment assistance to individuals who have applied for services through HHSC until HHSC completes development of the individual plan for employment (IPE).

HHSC does not authorize payment for training that is not directly related to an individual's employment assistance program. The following activities may be billed to the CLASS program if included in the individual's authorized IPC:

  • identifying an individual's employment preferences, job skills, and requirements for a work setting and work conditions;
  • locating prospective employers offering employment compatible with an individual's identified preferences, skills and requirements;
  • contacting a prospective employer on behalf of an individual and negotiating the individual's employment;
  • transporting the individual to help the individual locate competitive employment in the community; and
  • participating in SPT meetings.

 

7250 Transition Assistance Services (TAS)

Revision 15-2; Effective November 20, 2015

 

TAS assists an individual in setting up a household in the community before being discharged from a nursing facility or an intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID) and enrolling in the CLASS program. There is a cost limit of $2,500 for TAS and an individual may receive TAS only once in the individual's lifetime. TAS is not available if an individual's enrollment IPC includes support family services or continued family services in the CLASS program.

Available services include:

  • payment of security deposits required to lease a home, including an apartment, or to establish utility services for a home;
  • the purchase of essential furnishings for a home, including a table, bed, chairs, window blinds, eating utensils and food preparation items;
  • payment of expenses required to move personal items, including furniture and clothing, into a home;
  • payment for services to ensure the health and safety of the individual in a home, including pest eradication, allergen control or a one-time cleaning before occupancy; and
  • the purchase of essential supplies for a home, including toilet paper, towels and bed linens. For more details, see 40 Texas Administrative Code, Part 1, Chapter 62, Transition Assistance Services.

 

7260 Support Family Services (SFS) and Continued Family Services (CFS)

Revision 11-1; Effective June 13, 2011

 

 

 

7261 SFS

Revision 17-1; Effective November 1, 2017

 

SFS consist of services required for an individual under age 18 in the CLASS program to reside within the home of a family other than the home of the natural or adopted parent(s). The support family agency will recruit, train and certify the SFS provider. The SPT, including the support family agency, will coordinate placement into an SFS provider.

The support family agency must be licensed by the Department of Family and Protective Services (DFPS) as a child placing agency and maintain a current Medicaid provider agreement with HHSC to provide SFS.

SFS is reimbursed at a daily rate to provide 24-hour services that include:

  • direct personal assistance with an ADL (e.g., grooming, eating, bathing, dressing and personal hygiene);
  • assistance with meal planning and preparation;
  • assistance with securing and providing transportation;
  • assistance with housekeeping;
  • assistance with ambulation and mobility;
  • reinforcement of counseling, therapy and educational activities;
  • assistance with medications and the performance of tasks delegated by an RN;
  • supervision of the individual's safety and security;
  • facilitating inclusion in community activities, by the use of natural supports, social interaction, participation in leisure activities and development of socially valued behaviors; and
  • services that train the individual to acquire, retain, and improve self-help, socialization, and daily living skills or assisting the individual with ADLs.

 

7262 CFS

Revision 17-1; Effective November 1, 2017

 

CFS is for people who are unable to continue with SFS. CFS provides a 24-hour family living arrangement in a home using the same criteria for SFS and meeting the requirements of a support family home. The continued family agency will recruit, train and certify the CFS provider. The case manager, the continued family agency, the natural family and the DSA will coordinate placements into a CFS provider.

A continued family agency must be licensed by DFPS as a child placing agency and maintain a current Medicaid provider agreement with HHSC to provide CFS.

CFS is reimbursed at a daily rate to provide 24-hour services that include:

  • direct personal assistance with an ADL (e.g., grooming, eating, bathing, dressing and personal hygiene);
  • assistance with meal planning and preparation;
  • assistance with securing and providing transportation;
  • assistance with housekeeping;
  • assistance with ambulation and mobility;
  • reinforcement of counseling, therapy and educational activities;
  • assistance with medications and the performance of tasks delegated by a registered nurse;
  • supervision of the individual's safety and security;
  • facilitating inclusion in community activities by the use of natural supports, social interaction, participation in leisure activities and development of socially valued behaviors; and
  • services that train the individual to acquire, retain, and improve self-help, socialization, and daily living skills or assisting the individual with ADLs.

 

7270 Adaptive Aids, Minor Home Modifications and Dental Treatment

Revision 17-1; Effective November 1, 2017

 

 

7271 Adaptive Aids

Revision 12-2; Effective October 17, 2012

 

An adaptive aid is an item or service that enables an individual to retain or increase the ability to perform ADL or perceive, control or communicate with the environment in which the individual lives.

The maximum allowable for adaptive aids and dental treatment combined is $10,000 per IPC period for an adaptive aid listed in Appendix I, Adaptive Aids.

The following may be billed under the CLASS program if included in the individual's authorized IPC:

  • actual cost of the adaptive aid;
  • repair and maintenance of an adaptive aid not covered by warranty;
  • the cost of a specification for the adaptive aid;
  • the cost of an independent inspection performed by a certified automotive technician on a vehicle that is expected to be modified or adapted, according to Appendix I. The cost of this inspection must not exceed $150;
  • the cost of insurance copayments for therapeutic services limited to those therapeutic services available in the CLASS program; and
  • rental of equipment, not to exceed 90 days, to:
    • evaluate the benefit on a trial basis for a short period of time; or
    • allow for the repair, purchase or replacement of essential adaptive aids.

 

7272 Minor Home Modifications

Revision 12-1; Effective January 13, 2012

 

A minor home modification is a physical adaptation to an individual's residence is necessary to address the individual's specific needs and enables the individual to function with greater independence in the individual's residence or to control his or her environment.

The maximum allowable for minor home modifications is $10,000 for the lifetime of the individual and up to $300 per IPC period for repair and maintenance of minor home modifications purchased through the CLASS program after the lifetime cost limit has been met.

The following may be billed under the CLASS program if included in the individual's authorized IPC:

  • actual cost of the minor home modification, including installation;
  • repair and maintenance of a minor home modification not covered by warranty after one year has passed from the date the minor home modification was completed;
  • the cost of a specification for the minor home modification; and
  • the cost of an inspection of the minor home modification.

If the minor home modification has several components, these may be billed separately as they are completed (e.g., bathroom modification that involves widening a doorway, adding grab bars to the tub and installing a special toilet adaptation). Materials may be billed separately from the labor necessary to complete the task.

 

7273 Dental Treatment

Revision 17-1; Effective November 1, 2017

 

The following routine preventive, therapeutic, orthodontic and emergency dental treatment may be billed under the CLASS program if included in the individual's authorized IPC:

  • procedures necessary to control bleeding, relieve pain and eliminate acute infection;
  • operative procedures required to prevent the imminent loss of teeth;
  • treatment of injuries to the teeth or supporting structures;
  • examinations;
  • x-rays;
  • cleanings;
  • sealants;
  • oral prophylaxes;
  • topical fluoride treatment;
  • fillings;
  • scaling;
  • extractions;
  • crowns;
  • pulp therapy;
  • restoration of caries (cavities);
  • maintenance of space;
  • limited provision of removable prostheses when masticatory function is impaired, when an existing prosthesis is un-servable, or when aesthetic consideration interfere with employment or social development;
  • treatment of retained deciduous teeth;
  • treatment of cross-bite therapy;
  • treatment of facial accidents involving severe traumatic deviations;
  • treatment of cleft palates with gross malocclusion;
  • treatment of handicapping malocclusions affecting permanent dentition with a minimum score of 26 as measured on the Handicapping Labio-lingual Deviation Index; and
  • sedation necessary to perform dental treatment including non-routine anesthesia (e.g., intravenous sedation, general anesthesia or sedative therapy prior to routine procedures).

Cosmetic orthodontia is excluded from CLASS program services.

 

7280 Transportation-Habilitation, CFC PAS/HAB and Respite Care

Revision 17-1; Effective November 1, 2017

 

 

 

7281 Transportation - Habilitation

Revision 17-1; Effective November 1, 2017

 

A program provider must ensure a transportation-habilitation service provider who is hired on or after July 1, 2015, has:

  • a high school diploma or a certificate recognized by a state as the equivalent of a high school diploma; or
  • both of the following:
    • a successfully completed written competency-based assessment demonstrating the service provider's ability to perform habilitation, including an ability to perform habilitation tasks required for the individual to whom the service provider will provide habilitation; and
    • at least three written personal references from persons who are not relatives of the service provider that evidence the service provider's ability to provide a safe and healthy environment for the individual.

The following activities may be billed to the CLASS program if included in the individual's authorized IPC:

  • time spent in direct contact with the individual that includes time spent by the habilitation service provider delivering transportation services according to the Individual Program Plan (IPP), Individual Program Plan Addendum (IPP-A), IPC and habilitation plan or transportation plan;
  • time spent participating on the SPT as the appropriate DSA representative, if the person attending meets the qualifications as the official representative of the DSA;
  • time spent operating a vehicle while transporting an individual according to the IPP, IPP-A and Transportation Plan.

 

7281.1 Community First Choice (CFC) Personal Assistance Services/Habilitation (PAS/HAB)

Revision 17-1; Effective November 1, 2017

 

Effective June 1, 2015, the majority of activities previously included as part of the CLASS habilitation services are now available through the non-waiver Medicaid state plan CFC PAS/HAB service.

A program provider must ensure a CFC PAS/HAB service provider has:

  • a high school diploma or a certificate recognized by a state as the equivalent of a high school diploma; or
  • both of the following:
    • a successfully completed written competency-based assessment demonstrating the service provider's ability to perform habilitation, including an ability to perform habilitation tasks required for the individual to whom the service provider will provide habilitation; and
    • at least three written personal references from persons who are not relatives of the service provider that evidence the service provider's ability to provide a safe and healthy environment for the individual.

The following activities may be billed to CFC PAS/HAB if included in the individual's authorized IPC:

  • personal assistance services that provide assistance to an individual in performing ADLs and IADLs based on the individual's person-centered service plan, including:
  • non-skilled assistance with the performance of the ADLs and IADLs;
  • household chores necessary to maintain the home in a clean, sanitary, and safe environment;
  • escort services, which consist of accompanying and assisting an individual to access services or activities in the community, but do not include operating a vehicle while transporting an individual; and
  • assistance with health-related tasks; and
  • habilitation that provides assistance to an individual in acquiring, retaining and improving self-help, socialization and daily living skills and training the individual on ADLs, IADLs and health-related tasks, such as:
    • self-care;
    • personal hygiene;
    • household tasks;
    • mobility;
    • money management;
    • community integration, including how to get around in the community;
    • use of adaptive equipment;
    • personal decision making;
    • reduction of challenging behaviors to allow individuals to accomplish ADLs, IADLs, and health-related tasks; and
    • self-administration of medication.

 

7281.2 Community First Choice (CFC) Support Management

Revision 17-1; Effective November 1, 2017

 

CFC support management offers training on how to select, manage, and dismiss an unlicensed service provider of CFC PAS/HAB. There is no reimbursement rate for CFC Support Management. CFC Support Management is available to all individuals and is different from CDS Support Consultation as described in Section 4100. A Financial Management Services Agency (FMSA) are required to offer support management.

 

7282 Respite Care

Revision 17-1; Effective November 1, 2017

 

An individual is eligible for respite if:

  • the person who routinely provides assistance and support and resides with the individual is temporarily unavailable to provide the routine assistance and support;
  • the amount of respite does not exceed the amount of unpaid assistance and support routinely provided by the person who routinely provides this assistance and support;
  • the service provider of respite or employee in the CDS option of respite does not reside with the individual; and
  • the individual does not receive support family services or continued family services at the same time as respite is being provided;
  • respite is reimbursed at a daily rate to provide the following services for 24 hours;
  • interacting face-to-face with an individual who is awake to assist the individual in the following activities;
    • self-care;
    • personal hygiene;
    • ambulation and mobility;
    • money management;
    • community integration;
    • use of adaptive equipment;
    • self-administration of medication;
    • reinforce any therapeutic goal of the individual;
    • provide transportation to the individual; and
    • protect the individual's health, safety and security;
  • interacting face-to-face or by telephone with an individual or an involved person regarding an incident that directly affects the individual's health or safety; and
  • performing one of the following activities that does not involve interacting face-to-face with an individual:
    • shopping for the individual;
    • planning or preparing meals for the individual;
    • housekeeping for the individual;
    • procuring or preparing the individual's medication;
    • arranging transportation for the individual; or
    • protecting the individual's health, safety and security while the individual is asleep.

Because respite includes personal care, the provider may not bill for habilitation when the individual is in the respite setting. The provider may bill for other CLASS program services the individual requires while in the respite setting. The provider may not bill for minor home modifications made to an out-of-home respite setting.

 

7290 Pre-Enrollment Assessments

Revision 17-1; Effective November 1, 2017

 

The CMA is reimbursed a pre-enrollment assessment fee for providing case management services necessary to enroll an applicant into the CLASS program. The pre-enrollment assessment fee reimburses costs prior to the date the applicant is determined to be eligible for CLASS services.

For a full assessment fee, the case manager must submit a completed Form 3621, CLASS/CFC – Individual Plan of Care, along with a completed Form 3625, CLASS/CFC – Documentation of Services Delivered.

A partial assessment fee may be requested in the event the applicant declines CLASS program services or does not meet eligibility requirements. For a partial assessment fee, the case manager must submit a completed Form 3657, Pre-Enrollment Assessment, which should be submitted with completed Form 3625 to HHSC.

The DSA is reimbursed a pre-enrollment assessment fee for providing pre-enrollment activities necessary to enroll an applicant into the CLASS program as outlined in Section 3310, Enrollment. The pre-enrollment assessment fee reimburses costs prior to the date the applicant is determined to be eligible for CLASS services.

 

7300 Non-Billable Time and Activities

Revision 17-1; Effective November 1, 2017

 

The following are examples of non-billable time and activities:

  • phone calls, letters or meetings with HHSC or non-CLASS resources when the activity does not benefit a specific individual;
  • administrative meetings or staff meetings;
  • in-service training, continuing education or conferences;
  • employee conferences or evaluations;
  • filing claims for services;
  • traveling to and from the individual's home, unless the service provider is accompanied by the individual receiving services;
  • travel time spent by the DSA staff to obtain, purchase or deliver an adaptive aid;
  • processing paperwork;
  • minor home modifications not listed in Appendix II, Minor Home Modification Services, as available items;
  • adaptive aids not listed in Appendix I, Adaptive Aids, as available items;
  • adaptive aids or medical supplies offered as pre-owned, used or refurbished;
  • collateral contact when that contact is between a program provider's service providers;
  • "down-time" such as illness, holidays or vacation time;
  • contact with the individual or LAR while admitted to an institutional setting (hospital, nursing facility, rehabilitation hospital, intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID), state supported living center or state hospital);
  • collateral contact (telephone or face to face) to assist or discuss a specific individual services (e.g., helping access non-CLASS resources);
  • leaving a phone message on a recorder or leaving a message with anyone other than the individual or LAR;
  • direct contact with the individual or LAR by a DSA representative when contact is about coordination of service providers or finding replacement service providers — the cost associated with this time is an allowable cost and should be reported in the DSA's cost report;
  • mediation/problem-solving performed by a DSA representative between the CLASS service provider and the individual — the cost associated with this time should be reported in the DSA's cost report; and
  • time spent by a DSA representative to train a direct service provider.

 

7400 Duplicate Services

Revision 17-1; Effective November 1, 2017

 

A direct service provider may bill for only one service at a time. Examples include:

  • A transportation-habilitation service provider transports an individual to community services for one hour while discussing life skill training with the individual. The provider may only bill for one unit of habilitation, not two.
  • A CFC PAS/HAB service provider spends one hour cooking a meal while teaching the individual to cook at the same time. The provider agency may bill for only one unit of habilitation, not two.
  • An individual who is receiving CFC PAS/HAB services may not simultaneously receive respite services.

 

7500 Billable Units

Revision 17-1; Effective November 1, 2017

 

A billable unit of service is the method for calculating the amount the provider agency may bill HHSC. Units are measured by increments of time or by the cost of the item provided.

 

7510 Services Unit Measurements

Revision 17-1; Effective November 1, 2017

 

The following services use time as the measure. One unit of service is defined as:

Case Management monthly rate
Transportation-Habilitation one hour
CFC PAS/HAB one hour
Nursing one hour
Occupational Therapy one hour
Physical Therapy one hour
Speech and Language Pathology one hour
Cognitive Rehabilitation Therapy one hour
Behavioral Support Services one hour
Dietary Services one hour
Respite one 24-hour period
Specialized Therapies one hour
Supported Employment one hour
Employment Assistance one hour
Prevocational Services one hour
Support Family Services daily rate
Continued family services daily rate

The following services are measured by the cost of the item provided:

  • adaptive aids
  • minor home modifications
  • dental services
  • TAS

All services measured by the hour use the following formula to calculate the billable unit, unless the service is respite.

Number of providers × time spent delivering services ÷ number of individuals served = billable unit of services
Examples:
1 provider × 1 hour of service ÷ 1 individual = 1 billable hour
1 provider × 1 hour of service ÷ 2 individuals = 1/2 hour billable per individual
1 provider × 1 hour of service ÷ 3 individuals = 1/3 hour billable per individual
2 providers × 1 hour of service ÷ 3 individuals = 2/3 hour billable per individual

 

7520 Respite Care

Revision 11-1; Effective June 13, 2011

 

The unit of service for respite care is defined as a 24-hour period. The respite rate is billed for each individual in a respite setting.

Examples
One individual in a respite setting for 24 hours = 1 billable unit
Two individuals in a respite setting for 24 hours = 1 billable unit per individual
Three individuals in a respite setting for 24 hours = 1 billable unit per individual

 

7600 Billing Partial Units

Revision 11-1; Effective June 13, 2011

 

To arrive at a monthly total for services that have one hour as the unit of service, add all units of a single type of service provided by all service providers of that service during the month. If the monthly total is not a whole number, or 1/4 unit increments, round the total up to the nearest 1/4 unit. Convert the partial unit to the decimal equivalent when billing:

1-15 minutes of service = unit (.25)
15.1 minutes to 30 minutes = unit (.5)
30.1 minutes to 45 minutes = unit (.75)
45.1 minutes to 60 minutes = 1 unit (1.0)

Example

Habilitation service provider A

= 12 hours and 12 minutes

Habilitation service provider B

= 5 hours

Habilitation service provider C

= 4 hours and 15 minutes

Total time for May

= 21 hours and 27 minutes

Billable habilitation units for May

= 21.5 (twenty-one and one-half)

 

 

 

7610 Billing Units of Respite Service

Revision 11-1; Effective June 13, 2011

 

Partial units of respite are calculated as follows:

1 hour of service
2 hours of service
3 hours of service
4 hours of service
5 hours of service
6 hours of service
7 hours of service
8 hours of service
9 hours of service
10 hours of service
11 hours of service
12 hours of service
13 hours of service
14 hours of service
15 hours of service
16 hours of service
17 hours of service
18 hours of service
19 hours of service
20 hours of service
21 hours of service
22 hours of service
23 hours of service
24 hours of service

=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=

1/24 unit (.04)
2/24 unit (.08)
3/24 unit (.12)
4/24 unit (.17)
5/24 unit (.21)
6/24 unit (.25)
7/24 unit (.29)
8/24 unit (.33)
9/24 unit (.37)
10/24 unit (.42)
11/24 unit (.46)
12/24 unit (.50)
13/24 unit (.54)
14/24 unit (.58)
15/24 unit (.62)
16/24 unit (.67)
17/24 unit (.71)
18/24 unit (.75)
19/24 unit (.79)
20/24 unit (.83)
21/24 unit (.87)
22/24 unit (.92)
23/24 unit (.96)
24/24 unit (1.0)

 

7620 Billing Units of Out-of-Home Respite Service

Revision 11-1; Effective June 13, 2011

 

The DSA must use the following procedure to bill as closely as possible to the actual cost for out-of-home respite services delivered. To calculate the units of respite that the DSA would bill for, the provider needs to calculate to the nearest partial unit the amount that allows adequate reimbursement to cover the actual cost of the service based on the current out-of-home respite rate per 24-hour period. This is done by dividing the total actual cost for respite by the current daily rate.

Administrative costs to the DSA related to arranging for respite services cannot be included in this billing calculation but should be reported on the DSA's cost report.

 

7700 Record Keeping Requirements

Revision 11-1; Effective June 13, 2011

 

The provider agency must maintain financial and supporting documents, statistical records and any other records pertinent to the services for which a claim or cost report was submitted to the department or its agent. If a provider agreement or contract has no specific termination date in effect, the records and documents must be kept for a minimum of three years and 90 days after the end of the federal fiscal year in which services were provided. If any litigation, claim or audit involving these records begins before the three-year period expires, the provider agency must keep the records and documents for at least three years and 90 days or until all litigation, claims or audit findings are resolved. The case is considered resolved when a final order is issued in litigation or the department and provider agency enter into a written agreement. The provider agency must keep records of non-expendable property acquired under the contract for three years after the final disposition of the property. In this section, contract period means the begin date through the end date specified in the original contract; extensions are considered separate contract periods.

The provider agency must maintain medical records for five years from the date the last services were delivered to the individual by the provider agency.

Medical records include:

  • Form 8578, Intellectual Disability/Related Condition Assessment;
  • assessments and evaluations containing individual medical information;
  • any other records containing individual medical information;
  • physician orders; and
  • Individual Plan of Care/Individual Program Plan.

 

7800 Service Delivery Records

Revision 17-1; Effective November 1, 2017

 

The CMA will maintain individual records that contain information required by HHSC and CLASS for a period of six years. Documentation must be maintained in each individual's record to include:

  • identifying information — name, sex, race, date of enrollment, citizenship, residence, marital status, Social Security number, Medicaid number;
  • name, address and phone number of responsible or interested parties;
  • financial information (income);
  • incident reports;
  • if the individual requires supported employment services and is not already employed, written verification of HHSC determination of eligibility or denial of supported employment services;
  • if the individual requires employment assistance services, written verification of the HHSC determination of eligibility or denial of supported employment services unless CLASS employment assistance services are being provided while awaiting HHSC to develop an individual plan for employment (IPE) for the individual;
  • case management activities to include the:
    • date of contact;
    • description of the case management provided;
    • progress or lack of progress in achieving goals or outcomes in observable, measurable terms that directly relate to the specific goal or objective addressed;
    • person with whom the contact occurred; and
    • case manager who provided the contact.
  • if the individual is in school, the individual education plan (IEP) for the individual;
  • discharge summaries; and
  • additional required documentation:
    • individual's current IPC;
    • individual’s current person-centered plan, IPP-A
    • individual's current IPP;
    • individual's current Intellectual Disability/Related Condition (ID/RC) Assessment; and
    • any other relevant documentation concerning the individual.

The DSA will maintain individual records that contain information required by HHSC and CLASS for a period of six years. Documentation must be maintained in each individual's record to include:

  • identifying information — name, sex, race, date of enrollment, citizenship, residence, marital status, Social Security number, Medicaid number;
  • name, address and phone number of responsible or interested parties;
  • physicians' orders for medications and treatments, and any other medical records;
  • consent statements for money management;
  • evaluations of progress towards individual goals to include the:
    • type of CLASS program service provided;
    • date and the time the service begins and ends;
    • type of contact (phone or face-to-face);
    • name of the person with whom the contact occurred;
    • description of the activities performed, unless the activity performed is a non-delegated task that is provided by an unlicensed service provider and is documented on the IPP; and
    • signature and title of the service provider;
  • incident reports;
  • trust fund records;
  • documentation that employment assistance or supported employment is not available to the individual under a program funded under §110 of the Rehabilitation Act of 1973 or under a program funded under the Individuals with Disabilities Education Act (20 U.S.C. §1401 et seq.); and
  • these forms, as identified in Title 40 of the TAC §45.807:
    • a copy of the individual's current IPC;
    • a copy of the individual’s current IPP-A;
    • a copy of the individual's current IPP;
    • a copy of the individual's current ID/RC Assessment;
    • a copy of the current adaptive behavior screening assessment;
    • a copy of the current HHSC CLASS/DBMD Nursing Assessment form
    • a copy of the current Related Conditions Eligibility Screening Instrument;
    • any new or revised Form 3628, Provider Agency Model Service Backup Plan, for the current IPC period; and
    • any other relevant documentation concerning the individual.

Evidence that employment assistance is not available to the individual under a program funded under §110 of the Rehabilitation Act of 1973 or under a program funded under the Individuals with Disabilities Education Act, must include documentation of the individual having applied for HHSC. Individuals receiving educational services through a school system must seek to have employment assistance or supported employment services included in the Individual Education Plan, when appropriate.

The requirement to document the service provided in an individual’s record does not apply if the service/activity performed is a non-delegated task provided by an unlicensed service provider that is documented on the IPP.